Manufacturing - Travelers



Supplemental Application

|SELECT – LABOR UNIONS |

|Applicant’s Name:       Effective Date:       |

|Agent Name and Phone:       |

|Risk Control Contact Name:       Phone Number:       |

|A. General Background |

|1. Union Name:       |

|2. What business sector does your union represent?       |

|3. How many members does your union represent?       |

|4. Do you have a website? | Yes | No |

| If yes, please provide URL: |

|      |

|B. Affiliated Unions |

|1. If affiliated with other unions, please answer the following questions: |

|2. Identify other Unions you are affiliated with:       |

|3. Are you required to indemnify them or hold harmless? | Yes | No |

|4. Are you required to name them as an additional insured on your GL policy? | Yes | No |

|C. Real Property Owned or Leased |

|1. Please list all real property you own or hold in trust for others: |

|      |

|2. Do you have a large meeting room or hall? | Yes | No |

|3. Do you rent any of your property to others for special events? | Yes | No |

| If yes, please describe the events and number of events per year. |

|a. Number of events:     |

|b. Description:       |

|4. Do you provide a 'hiring hall' for your members? | Yes | No |

|D. Job Actions | | |

|1. Has your union participated in any strikes, picketing, slowdowns, or any other job actions in the past five years? | Yes | No |

| If yes, please describe:       |

|E. Training or Apprenticeship Programs |

|1. Do you provide or conduct any training, vocational or apprenticeship programs? | Yes | No |

| If yes, please describe:       |

|2. How is training conducted? | Classroom | Field |

| | Other (please describe):       |

|F. Standard Setting | | |

|1. Please describe your involvement in developing, maintaining or supervising any job safety standards, manuals, training programs or performance standards. |

|      |

|G. Special Events |

|1. Please describe any special events you sponsor during the year (examples: conventions, tournaments, dances): |

|      |

|2. Do you serve or sell alcoholic beverages at any of these events? | Yes | No |

| If yes, please describe:       |

|H. Publishing or Advertising Activities | | |

|1. Please list names and types of publications (newsletters, magazines, manuals etc.) you create and publish. |

|      |

|2. Are your publications reviewed by legal counsel? | Yes | No |

|I. Union or Media Liability Insurance | | |

|1. Do you have a Union or Media Liability Policy | Yes | No |

|a. If yes, what is the limit of insurance and | |

|Insurance carrier? |Carrier Name: |

| $       |      |

|b. If no, have you ever been declined, cancelled or non-renewed a Union or Media Liability Policy in the past 3 years? | Yes | No |

|J. Member Services | | |

|1. Please describe any financial or legal services you provide to your members. (examples: insurance, banking, financial credit; personal legal services etc. |

|      |

|K. Automobile | | |

|1. How many employees use their personal vehicles for business purposes? |Number of employees       |

|2. Do you require evidence of personal auto insurance? | Yes | No |

|3. What is the minimum limit of insurance that they must carry? |$       |

|4. Do you obtain copies of the drivers Motor Vehicle records? | Yes | No |

|5. Do you provide transportation for employees or union members? | Yes | No |

|L. Financial Management | | |

|1. Do you collect and manage union dues? | Yes | No |

|2. Do you manage any pension plans for members? | Yes | No |

|3. Do you have any property you hold in trust or invest for others? | Yes | No |

|If yes, | | |

|a. Have you purchased a Labor Organization Bond? | Yes | No |

|b. Describe property:       |

|4. Maximum cash on hand $       | | |

|M. Losses | | |

|1. Please describe any losses you have had in the last 5 years. |

|      |

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Please read the statement applicable to your state. If your state and/or Line of Business are not listed, please read the statement applicable to All Other States. Then sign, date and return with your application.

ARKANSAS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

CALIFORNIA FOR AUTO: IN ADDITION, ANY PERSON WHO KNOWINGLY MAKES AN APPLICATION FOR MOTOR VEHICLE INSURANCE COVERAGE CONTAINING ANY STATEMENT THAT THE APPLICANT RESIDES OR IS DOMICILED IN THIS STATE WHEN, IN FACT, THAT APPLICANT RESIDES OR IS DOMICILED IN A STATE OTHER THAN THIS STATE, IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.

COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

DISTRICT OF COLUMBIA: WARNING:  It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person.  Penalties include imprisonment and/or fines.  In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

HAWAII: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

LOUISIANA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

MAINE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

MASSACHUSETTS FOR AUTO: NOTICE: If you or someone else on your behalf gives us false, deceptive, misleading, or incomplete information that increases our risk of loss, we may refuse to pay claims under any or all of the Optional Insurance Parts and we may cancel your policy. Such information includes the description and the place of garaging of the vehicle(s) to be insured, the names of operators required to be listed and the answers to questions in this application about all listed operators. Check to make certain that you have correctly listed all operators and the completeness of their previous driving records. The Merit Rating Board may verify the accuracy of the previous driving records of all listed operators, including that of the applicant for this insurance.

MINNESOTA: A PERSON WHO SUBMITS AN APPLICATION OR FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME.

NEW JERSEY: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

NEW MEXICO: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.

NEW YORK FOR AUTO: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION. FOR OTHER LINES OF BUSINESS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

OHIO: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.

OKLAHOMA: WARNING:  Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

OREGON: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact, may be violating state law.

PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND CIVIL PENALTIES.

RHODE ISLAND: In Rhode Island this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.

DURING THE LAST TEN YEARS, HAS ANY APPLICANT BEEN CONVICTED OF ANY DEGREE OF THE CRIME OF ARSON?

__________YES __________NO

TENNESSEE FOR WORKERS COMPENSATION: It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers' compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits. FOR OTHER LINES OF BUSINESS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.

UTAH FOR WORKERS COMPENSATION: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison.

VERMONT: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto, may be committing a crime, subjecting the person to criminal and civil penalties.

VIRGINIA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

WEST VIRGINIA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

ALL OTHER STATES: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties. Not applicable in Nebraska.

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CX-1396 (New 10-06) -1-

CX-1396 (New 10-06) -2-

CX-1396 (New 10-06) -3-

SIGNATURE OF APPLICANT DATE

06/23/05 Page 5 of 5

© 2005 The St. Paul Travelers Companies, Inc. All rights reserved.

FRAUD STATEMENT

06/23/05 Page 4 of 5

© 2005 The St. Paul Travelers Companies, Inc. All rights reserved.

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In order to avoid copyright disputes, this page is only a partial summary.

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